MULTIPLE

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MULTIPLE PULMONARY NODULES THE IMPORTANCE OF
THE COMPUTED TOMOGRAPHY (CT) IN THE ETIOLOGIC
ORIENTATION ABOUT 68 CASES
A. AROUS, A. MAALEJ, H. ABID, F. AKID, W. TURKI,
S. HADDAR, KH. BEN MAHFOUDH,  J.  MNIF CHU HABIB
BOURGUIBA SFAX - TUNISIA
ARAB CONGRESS OF RADIOLOGY 2012
CHEST IMAGING  CH 1
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INTRODUCTION

• A lung nodule is defined as a spot on the lung
  that is between 0.5 and 3 cm in diameter.
• If an abnormality is seen on an x-ray of the
  lungs that is larger than 3 cm, it is considered
  a mass instead of a nodule.
• The availability and increasing number of chest
  CT scans in patients with pulmonary complaint
  cause frequent incidental findings of multiple
  pulmonary nodules.
• The etiology of multiple pulmonary nodules can
  usually be determined with a thorough history and
  physical examination.
• However, further testing is sometimes required
  for diagnosis, which may include additional
  imaging and/or a biopsy.

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PURPOSE

• The objective of our study is to illustrate
  the contribution of the Computed Tomography (CT)
  in the etiologic diagnosis of the multiple
  pulmonary nodules.

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MATERIALS AND METHODS

• Retrospective study concerning 68 patients.
• Age varies between 4 years and 77 years.
• A thoracic CT was realized within the framework
  of a staging evaluation or control of a cancer
  (in 40 cases), or in front of a respiratory
  symptomatology with multiple pulmonary nodules in
  the chest radiography (in 28 cases).
• The diagnosis was confirmed in all cases by the
  biology or by histological study .

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RESULTS AND DISCUSSION
Number of cases Etiologies
46 Lung metastases
6 lymphoma lung nodules
4 tuberculosis
3 pulmonary aspergillosis
3 nodules rheumatoid
2 pulmonary staphylococcia
1 sarcoidosis
1 candidiasis
1 a Wegener's granulomatosis
1 non-specific interstitial pneumonia

• The diagnosis was confirmed in all cases by the
  biology or by histological study .

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RESULTS AND DISCUSSION

• These etiologies can be classified into three
  major categories
• Malignant tumor disease This includes lung
  cancer, lymphomas, and cancer that has spread to
  the lungs from other parts of the body, among
  others.
• Infectious disease This includes bacterial
  infections such as tuberculosis, fungal
  infections such as histoplasmosis 
  and coccidiomycosis, and parasitic infections .
• Inflammatory disease Conditions such
  as rheumatoid arthritis, sarcoidosis,
  and Wegeners granulomatosis can cause lung
  nodules.

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Malignant causes

• With regard to malignancy, multiple pulmonary
  nodules occur primarily as a manifestation of
  metastatic disease, which can come either from an
  adenocarcinoma of the lung or from a distant
  primary.
• Although it is not always recognized during life,
  30 to 40 of cancer patients have pulmonary
  metastases at autopsy.
• Cancer, particularly metastatic cancer, is a
  source of multiple pulmonary nodules, according
  to a 2007 article in the medical journal "Chest."
  
• Multiple pulmonary nodules evoke metastatic
  cancer. and the rate of malignancy in nodules
  gt20?mm is 81.

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• The nodules are variable in size and location,
  with a proclivity for the better perfused lung
  bases.
• The lesions are usually round with sharply
  demarcated borders, although metastases with a
  tendency towards hemorrhage, such as
  choriocarcinoma, can also have indistinct, fuzzy
  borders.
• Cavitation of metastatic lesions occurs in less
  than 5 percent of cases.
• Non-Hodgkin's lymphoma can also cause multiple
  pulmonary nodules these are more common in the
  lower lobes.
• Intrapulmonary lymphoma nodules usually originate
  from the bronchial-associated lymphoid tissue
  (BALT). Cavitation occurs in less than 4 percent
  of cases.

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• In our study, concerning malignant
  etiologies, we have found
• The central localization of the nodules
  predominate in 78 of patients having a malignant
  etiology.
• Lower lung distribution of nodules predominate in
  86 of cases.
• Solid nodules were found in all cases, while
  subsolid nodules were found in 4 of cases.
• Speculated and irregular contours were found in
  36 of cases.
• Lobulated contours were found in 7 of cases.
• Angiocentric nodules were found in 13 of cases.
• Excavated nodules were found in 13 of cases.
• Calcification were found in 5 of cases.

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Observation 1

• Patient follow-up for osteosarcoma
• multiple pulmonary nodules scattered throughout
  both lungs
• spiculated margin
• Cavitation
• Calcification
• Biopsy Osteosarcoma lung metastases

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Observation 2

• A women was diagnosed with an uterine
  carcinosarcomam since 2 years, consulting for
  chest pain.
• multiple well defined lung parenchymal nodules
  predominate in the middle and lower lung zones
• Excavated nodules in pulmonary apex
• Pulmonary metastasis of an uterine carcinosarcoma

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Observation 3

• An old man presents a dry cough with qn impaired
  general conditions
• Multiple pulmonary nodules with lower lung
  distribution
• Lobulated contours
• Angiocentric nodule
• Biopsy Large B cell lymphoma

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Observation 4

• Prolonged fever with cervical lymphadenopathy and
  dyspnea
• A chest x-ray demonstrated a widened mediastinum
• The chest CT scan demonstrated multiple pulmonary
  nodulesm one of them is excavated and present
  spiculated contours
• Multiple mediastinal lymphadenopathy with pleural
  effusion
• Biopsie Hodgkin's lymphoma

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Infectious causes

• According to a 2005 journal article in
  "Radiology," various infections can cause
  pulmonary nodules. Several types of fungal
  infections appear as pulmonary nodules on x-ray.
  These include
• Multiple abscesses bacteremic patients may
  develop multiple lung abscesses, which are more
  common in dependent areas of the lungs. Recurrent
  aspiration can yield multiple abscesses as well.
  Typically the lesions are between 0.5 and 3 cm in
  diameter, round, and well-defined. Formation of
  thick-walled cavities is common once the central
  necrotic debris has been expectorated through a
  bronchiolar communication.
• Septic emboli septic thrombophlebitis may
  generate septic emboli which produce multiple
  round or wedge-shaped nodules with a predilection
  for peripheral areas of the lower lobes.
  Cavitation is common, usually producing
  thin-walled lesions.

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• Fungi multiple pulmonary nodules can arise from
  a number of fungal infections, like
  histoplasmosis, coccidioidomycosis, or invasive
  Aspergillosis in immunocompromised hosts. In
  these cases, the lesions tend to range from 0.5
  to 3 cm in diameter without a clear predilection
  for a specific area of the lungs. Patients with
  invasive Aspergillosis commonly display a
  surrounding halo of ground glass attenuation due
  to local hemorrhage (the halo sign), followed by
  cavitation and "crescent-sign" formation.
• Tuberculomas of the lung are round or oval
  lesions situated commonly in an upper lobe, the
  right more often than the left. Typically they
  are sharply circumscribed and has a diameter
  ranging from 0.5 to 4 cm or more. Lobulation may
  be present in 25 of cases, and satellite lesions
  may be identified in up to 80 of cases.

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• In our study, concerning infectious
  etiologies, we have found
• The central localization of the nodules
  predominate in 80 of cases.
• Uper lung distribution of nodules predominate in
  80 of cases.
• halo sign were found in 2 cases of invasive
  aspergillosis.
• Subsolid nodules were found in 20 of cases.
• Excavated nodules were found in 30 of cases.
• Calcification were found in one case of
  tuberculosis.

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Observation 5

• Patient have received chemotherapy, present a
  persistent fever with neutropenia
• Chest CT scan revealed multiple nodules and
  demonstrate in the right upper lobe an excavated
  nodule surrounded by ground-glass attenuation
  (halo sign)
• Positive Aspergillus serology

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Observation 6

• A young man. fever, weight loss, night sweats,
  and cough with expectoration
• Subsolid nodules, it has indistinct margins
• excavated nodule in the left upper lobe
• Mycobacterium tuberculosis were found in a sputum
  sample

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Observation 7

• Prolonged fever, and cough
• Multiple pulmonary nodules, some of them are
  calcified
• Pulmonary tuberculosis confirmed with biological
  tests

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Inflammatory conditions

• Multiple pulmonary nodules may result from a
  number of noninfectious inflammatory conditions
• Wegener's Granulomatosis is the most common, it
  is a disorder causing inflammation of the blood
  vessels that affects the kidneys, lungs, and
  upper airway. It causes inflammatory tissues,
  called granulomas, to grow in and around the
  blood vessels. It can produce multiple round,
  sharply or poorly demarcated lesions varying in
  size from 0.5 to 10 cm. Areas of consolidation
  may be associated with nodules, and cavitation
  occurs in slightly less than one-half of
  patients, generally producing a thick wall with
  an irregular inner lining

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• Rheumatoid arthritis it causes rheumatoid
  nodules in different areas of the body including
  the lungs. Pulmonary nodules can appear before,
  with, or after the onset of RA. They are more
  commonly multiple than single, vary from a few
  millimeters to several centimeters in diameter,
  and tend to involve both lungs these nodules
  usually occur at the periphery of the lung, just
  beneath the pleura, and occasionally can cause
  bronchopleural fistula, pneumothorax, and abscess
  formation or cavitation leading to hemoptysis.
• Sarcoidosis Lung involvement in sarcoidosis has
  a strong predilection for the upper lung. sarcoid
  granulomas in the lung are typically distributed
  along the lymphatic vessels. The pattern of
  distribution, upper lung predominance, and
  coexistence of mediastinal lymphadenopathy
  strongly indicate the presence of sarcoidosis.
  Nodules have well defined but irrigular contours.

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• In our study, concerning noninfectious
  inflammatory conditions, we have found
• The peripheral localization of the nodules were
  found in all cases.
• Uper lung distribution of nodules predominate in
  sarcoidosis.
• Solid nodules with well defined contours were
  found in all cases.
• Excavated nodules were found in 40 of cases.
• Calcification were found in 2 case of rheumatoid
  nodules .

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Observation 8

• a woman followed for cutaneous sarcoidosis and
  has a dry cough with dyspnea.
• multiple lung nodules some of which haves
  irregular contours with subpleural distribution
• Bronchial distortion
• Pulmonary sarcoidosis was confirmed by biopsy of
  a lymphadenopathy

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Observation 9

• Pulmonary nodules in patients with Rhumatoide
  Arthritis
• Perilyphatic distribution of nodules
• Some of them are excavated
• Thickened interlobular septum
• Rheumatoid lung nodules

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Observation 10

• Male patient presented with history of cough with
  since two months.
• multiple pulmonary excavated nodules predominate
  in the right upper lobe withe a perepheral
  distribution
• The c-ANCA is positive Wegener's granulomatosis

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CONCLUSION AND POINTS TO REMEMBER (1)

• The multiple nodules must be analyzed according
  to semiological criteria concerning the aspect of
  margins and the distribution by taking into
  account the evolutionary context. The chest CT
  remains essential in the etiologic orientation
  and possibly in the histological confirmation.
• A basilar predominance is typically noted in
  hematogenous metastases due to preferential blood
  flow to the lung bases. Nodules may also be
  either cavitary or surrounded by a "halo" of
  ground-glass attenuation, which is typical of
  hemorrhagic metastases such as those due to
  choriocarcinoma.

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CONCLUSION AND POINTS TO REMEMBER(2)

• If nodules are clustered in a predominantly
  subpleural/axial distribution, they are deemed to
  be perilymphatic in distribution. The main
  disease to be considered is sarcoidosis.
• Less commonly, diffuse nodules may be identified
  in patients with septic emboli, invasive fungal
  infections, and pulmonary vasculitides. These
  entities frequently result in cavitary nodules,
  some with a distinct "halo" of ground-glass
  attenuation, and have even been described in
  patients with organizing pneumonia.

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